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In Somaliland, a health partnerships programme involving a small specialist NGO (THET) and King’s College Hospital NHS Foundation Trust (now part of an Academic Health Science Centre called Kings Health Partners) has supported the transition from immediate post-conflict health needs to a focus on health system strengthening. Emily Burn and Yassmin Mohamed from THET tell the story, and colleagues from health institutes and the Ministry of Health reflect on the partnership’s progress.

Background: Kings-THET-Somaliland Partnership

Somaliland’s self-declared independence (in May 1991) followed a civil war that saw the overthrow of the military dictator, Siad Barre, and the loss of thousands of lives to violence and famine. Despite on-going internal clan-based tensions and potential threats from the south, Somaliland has achieved an admirable level of stability in the last twenty years. In this context, the Kings-THET-Somaliland Partnership (KTSP) grew to support the development of Somaliland’s own skilled health workforce and improve health sector governance.

Established in 2000, KTSP’s first training trip was held at Edna Adan Maternity Hospital, Hargeisa. With support from THET, King’s staff members have made regular trips to the country. KTSP has grown its partner base throughout Somaliland to encompass health training institutions, professional bodies, and the Ministry of Health. Since its inception, KTSP has aimed to be responsive to, rather than instructive of, Somaliland’s own development, ensuring that the ownership and design of the partnership is rooted in Somaliland.

Initial focus was on the delivery of training and training materials to develop clinical and administrative staff capacity; this expanded to administrative staff capacity. Today, KTSP is providing support for governance activities in response to the increased capacity within the Ministry of Health to manage, plan and finance the health sector, and to work effectively with other actors in Somaliland. The partnership is also encouraging the development of independent regulatory accreditation and examination bodies that will ensure service delivery standards and the quality of ongoing support to health workers. Professional bodies also have an important role to play in acting as advocates for their members, offering representation in coordination and planning fora, and supporting health workers’ other needs, such as training.

Giving some context to her role and the Institute, Amina explained, “I am among the teachers who began this Institute in 2008. Back then, we had no support and as teachers we used our initiative and resources to build up this Institute. The first group [of students] are graduating in July 2011, the second group have just completed their first year and we are in the process of enrolling new students who will start the course in May 2011.”

Amina described how the Institute has benefitted from the partnership: “The Institute has seen a lot of benefits since joining the partnership in mid-2010. We receive support through the provision of books, training equipment, curriculum design and support with our finances. The partnership has supported our initiatives and allows us to train our healthcare workers. The Institute sends students to mother and child health centres and the two hospitals within the region of Sool (Central Referral Hospital and Manhal) to further develop their skills.”

When asked about her hopes for the future of the partnership, Amina replied, “I hope to see the Sool Institute progress alongside other members within Somaliland’s health sector. I hope to see cohesion and [that we will] continue to work together with the other institutes and within the partnership.”

Thinking about the benefits that the partnership has brought, Amina responded, “As a nurse, I possessed the skills to treat people and I had other skills that were not fully developed. Working for the Institute, and having access to the partnership, has allowed me to further my knowledge in administrative skills such as finance and planning, especially lesson planning. I hope to pass these skills on to my students and to encourage them to progress forwards and never backwards.”
(Interview April 2011)

Reflecting on the history of the partnership, Khadar gave this perspective: “The start of the health systems strengthening initiative in Somaliland in 2006 paved the way to advance receiving more strategic and harmonised assistance from DFID and other donors in health systems development, including investing in the integrated package of health care services.”

Support for the partnership from the UK side is voluntary and Khadar commented that: “Volunteer support provides CPD for senior health staff and the exchange of ideas and resources. As I know, they provide technical support to the academic management of the health institutions such as Amoud University, University of Hargeisa and nursing schools of Hargeisa, Burao and Las Anod. The volunteers also gain experience that builds on their own capacity and knowledge. The best things they [volunteers] do are the provision of the medical instructors to medical schools of Amoud University and University of Hargeisa. They also provide medical volunteers to the teaching hospitals like Edna and Hargeisa group hospitals.”

Regarding the partnership’s commitment long-term, Khadar felt that as long as the outcome is satisfactory, “…KTSP is one of the most successful programmes in Somaliland towards strengthening Somaliland’s health system.”

(Interview, January 2011 and correspondence, April 2011)

Fadumo Osman – Director of Buroa Institute of Health Sciences

Giving some background to the Institute, Fadumo explained, “I am the Director of this Institute, which has seen the graduation of 54 nurses in 2008 and 2010. We currently have 40 third-year students who are due to graduate this year, alongside 32 first-year students. In 2008 and 2009, we conducted training for 41 Community Health Workers from the surrounding villages, who have since begun work in these villages. Graduates from Buroa Institute have begun working across Somaliland especially in Sanaag.” [This region is further east and remote, which impacts the level of health care available to the residents].
Considering the benefits of the partnership, Fadumo described how: “We have a great partnership with THET, from which we have gained a lot of support, through teaching materials, laptops, photocopiers and books. Nine teachers were trained in Nursing Teacher Training in 2008-2009 and this has proved very useful in teaching our students. There have been numerous benefits from the partnership, most particularly with regards to teaching skills. We have also benefited from the monitoring and evaluating support received through this partnership, as it allows us to evaluate our work and improve our future efforts.

“We are the only institute in Buroa that offers medical training. Through the partnership, we have been able to improve teaching facilities and introduce new courses. In May 2011 we will start a midwifery course for graduates – there will be approximately 20 students enrolled on this course – and continue the general nursing course.”

Fadumo also gave her hopes for the future: “We hope to provide training in other medical areas, such as laboratory work, alongside the continuation of the midwifery course. We would also like to do a refresher teachers’ training, as this was extremely beneficial in our continuous efforts to improve our teaching facilities.”

Katia Eloi Cénat is a 32-year-old Haitian nurse. After the earthquake which struck Haiti on 12 January 2010, her right arm was amputated. Katia worked as a Psychologist’s Assistant for MSF, before joining Handicap International in October 2010, where she received on-the-job training as a Rehabilitation Technician. She speaks about her experiences here.

“Today we visited Mr Augustin,” explains Katia. “He is 54 years old, and was working in a funeral home when the earthquake hit. He was the only survivor in the building. He had to undergo a mid-thigh amputation and his other leg remained extremely weak, affecting his balance. Handicap International provided him with a walker and fitted him with a prosthesis, which allowed him to recover some mobility.

However, he cannot yet make full use of this equipment as he is still unable to stand up straight and has to spend a lot of time in his wheelchair. Despite all this, every Friday he makes his own way to church using his walker and prosthetic limb. We worked with him at home to improve his balance and strengthen his muscles, and referred him to the Handicap International Orthopaedic Centre in Port-au-Prince to deal with his healthy leg. His case is extremely complicated but he is very brave, always encouraging others at the centre, even though his own progress remains limited.

“At the centre, we provide rehabilitation services for amputees like Mr Augustin and we make prostheses and orthoses. As a Rehabilitation Technician, I assist physiotherapists, with the aim of making people with disabilities more independent. I am also part of a mobile team, along with a Physiotherapist and a Prosthetics & Orthotics Technician, providing patient follow-up at home and identifying problems they may encounter in their daily lives, such as stairs or obstacles in the house.

“When an amputee arrives at the centre, we start by taking measurements and producing a cast of their stump. Then we prepare the socket and make an appointment for the patient to have a static trial of their prosthesis. If this is successful, dynamic trials are then carried out once a week for one to five weeks. The number of sessions depends on the patient’s physical capacity – for example, elderly people may tire quickly, whereas children adapt much more easily.

During these sessions we carry out functional rehabilitation using muscle training exercises and give the patient exercises to do at home. If the amputee is suffering from psychological trauma, such as difficulty accepting their condition, we refer them to our psycho-social team. For problems related to their home environment, our accessibility team can carry out alterations to make their homes or the plot of land where they live more accessible.

“The patient has follow-up appointments, every two weeks at first, reducing to once a month, then once every two months. During these sessions, we check that the patient feels comfortable with their prosthesis and we train them to carry out day-to-day activities, such as carrying heavy loads. We also check their stump and gait cycle, to ensure they complete the stance and swing phases correctly, and address any abnormalities through specific exercises.

“The idea is to help amputees become as independent as possible in their daily lives so they can use the toilet, take a shower or cook unassisted. If necessary we can resolve problems on the spot by adapting their living space. We analyse what the patient can and cannot do in their home and, where necessary, provide them with technical aids that we make in our workshop. For example, a brush for washing clothes that can be attached to a leg, nail clippers that can be operated using an elbow, or a chopping board that can be fixed to the table with a clamp.

“We may also suggest simple techniques to negotiate obstacles like steep slopes, stairs, rocky paths or ditches. Some families live in houses built on the edge of a cliff or ravine and use bags of earth to make steps or section off a plot of land, making it very difficult for someone using a prosthesis to access the house. We may ask a patient’s family for support if a patient finds it difficult to put on their prosthesis, or to help them do their daily exercises.

“On average we see three or four patients a day, but sometimes we may only see one patient if they live in a particularly isolated area. Port-au-Prince is not very suitable for vehicles so we often leave the car and finish our journey on foot through the city’s alleyways. We spend around one hour with each patient, sometimes longer if the technician has to work on the prosthesis. What is really important is that we reach the most vulnerable and isolated people.

“Some cases are more complicated than others. Each case is different, depending both on the level and type of amputation, and the family and physical environment. The aim is to find the right solution for each person, and that is what I like best about my work.”

Handicap International is an international aid organisation working in situations of poverty and exclusion, conflict and disaster in over 60 countries worldwide.

The cluster approach to humanitarian disasters offers NGOs the opportunity for greater engagement and influence in humanitarian action. It also presents new practical and (for some NGOs) ethical challenges which each NGO must consider when deciding to participate. Linda Doull, Director of Health and Policy at Merlin, asks: Is cluster engagement a worthwhile investment for NGOs? She reflects on Merlin’s experiences at global and country level in this area since 2005. She discusses the challenges faced and how NGOs need to face up to the criticisms aimed at them.

Background to the cluster approach

In 2005, the cluster approach was launched by the Inter-Agency Standing Committee as one of the three pillars of humanitarian reform. It aims to ensure a more timely, predictable and effective response to humanitarian crises. Today there are 12 clusters. The approach has been implemented in 26 countries since its inception, most recently in Libya.

Through the Principles of Partnership, the cluster approach promotes a more effective and collaborative way of working among the wide range of humanitarian actors within the international system. The intended result is more effective humanitarian action through more transparent inter-agency dialogue, greater recognition of each agency’s role and capacity and their explicit role commitment to each response. The designers of the cluster approach recognized the key role played by both international and national NGOs in every humanitarian response. They promoted increased NGO engagement at country and global level.

Two major external evaluations and several reviews undertaken by NGOs, suggest that, while far from perfect, the cluster approach with NGO engagement, adds value. But there are important questions about how NGOs engage now and in the future. Each NGO should consider whether cluster engagement is a worthwhile investment for them and the response in general. Merlin’s reflections are below.
Why did Merlin become a cluster partner?

Merlin was invited to join the Global Health Cluster by the World Health Organization (health cluster lead agency) based on our commitment to and track record of supporting humanitarian health action in both acute and protracted complex emergencies. Merlin took the strategic decision to become a cluster partner because the approach:

Fitted with organizational remit and objectives;

Matched Merlin’s commitment to partnership working and belief in the power of collective action;

Created opportunities for enhanced resource mobilization and capacity, and

Created opportunities to be a catalyst for change, influencing humanitarian health action and promoting the role of NGOs.

What role has Merlin played?

Country level

Merlin has participated in a wide range of cluster activities at country and global level. The greatest engagement is at country level where teams play an active role in defining and delivering the health cluster response strategy for each crisis. Merlin automatically participates in the health cluster as soon as the cluster is officially activated and becomes the main coordination mechanism for the health sector response.

Merlin teams help to identify critical service delivery gaps and inform strategic decision-making either through joint assessment, or by regularly sharing information with the health cluster coordination team. Once identified, Merlin ‘fills the gap’ by supporting the Ministry of Health to deliver health assistance, in accordance with the comprehensive service package agreed by health cluster partners.
Through joint planning, Merlin and other cluster partners avoid geographical overlap and service duplication, making effective use of available resources. Merlin also uses its presence and technical expertise to strengthen the health cluster coordination. In Myanmar, we seconded a health information expert to the cluster to coherently manage the overwhelming amount of data received. In both Democratic Republic of Congo and Myanmar our established relations with local NGOs enabled them to access emergency funding and present their views to the authorities.

One of Merlin’s most important contributions – and greatest challenges – has been in the role of cluster co-steward, supporting WHO at national and sub-national level to implement the health cluster strategy. Merlin took on this new role in Myanmar, DRC and Somalia/Puntland, seconding senior staff to strengthen health cluster coordination, particularly at sub-national level, where WHO often has a limited presence. The experience has been important in clarifying the value of co-leadership; the skills, experience and resources needed, and the value NGOs can bring.

Global level

The Working Group which focuses on the development and dissemination of cluster tools and guidance; training for health cluster coordinators (including staff nominated from NGOs); and joint country support missions, such as the one Merlin undertook in Afghanistan.

The Policy and Strategy Team where Merlin has actively contributed to the development of GHC position papers on user fees and civil–military co-ordination, designed to assist country teams in decision making. Merlin also represents the GHC to major stakeholders, including donors.

What are the benefits of cluster engagement?

Merlin’s engagement in the health cluster at country and global level has required considerable effort but our internal reviews indicate it has largely been worth the investment. Particular benefits include gaining greater understanding of the humanitarian system and each specific context; increased access to information to enhance our decision-making and programming; access to funding through participation in Flash Appeals and other mechanisms; more open dialogue and strengthened relations with national authorities, UN agencies and donors; increased influence on sector policy and practice; and opportunities to innovate and learn from new ways of working leading to quality improvements with Merlin and beyond.
What are the challenges of being a cluster partner?

Merlin’s engagement in the health cluster has been invigorating and beneficial, but we have faced challenges. An internal review and consultation with other health cluster partners across ten countries identified similar challenges including: the issue of time commitment needed to participate in cluster meetings; ensuring suitably experienced staff are available for key activities such as joint assessments, country support visits and being co-steward; financial resources (all cluster partners are encouraged to mainstream costs within existing budgets, but some activities (e.g. being co-steward) are not cost neutral); the need for more awareness of, and training in, the use of cluster tools such as Initial Rapid Assessment and the Health Resources Availability Mapping System; and ensuring information from the GHC filters through to country health cluster teams.

In addition to these important operational issues, Merlin has reflected on wider concerns raised. Firstly, does being a partner in this UN-led approach reduce our independence as a humanitarian NGO? To date, Merlin does not feel this has been a problem, but remains vigilant in our risk assessment in each given context. Secondly, how can local NGOs and the Ministry of Health participate more effectively in the health cluster? Merlin’s experience shows that it has an important enabling role, using existing in-country relations with both, to bring them and/or their information to cluster meetings, to enhance inter-agency dialogue, planning and response.

Looking ahead

Delivering timely, effective and predictable responses to humanitarian crises will remain a priority in the years ahead as the frequency and scale of crises increases. The humanitarian sector acknowledges that – despite its well-documented faults – the cluster approach adds value. Based on learning to date, the role of NGOs within it should be enhanced. Encouraging though this is, if we are to be effective, NGOs must also think hard about two key criticisms aimed at us:

Too many participating NGOs hinders rather than helps cluster effectiveness. In Haiti nearly 400 health NGOs registered as cluster partners, many with no previous experience in such a crisis, and made a limited contribution to strategic dialogue and planning.

Being a cluster partner means sharing the challenges and identifying solutions to deliver coherent humanitarian health action, as opposed to the ‘opt-in’ / ‘opt-out’ approach adopted by some NGOs when the situation becomes complex.

Is cluster engagement a worthwhile investment for NGOs? From Merlin’s experience – yes – so long as you are clear about your added value; are willing to commit the time, energy and resources to engage; and are willing to adapt to new ways of working and learn from the individual and collective experience.

Fishing communities in Uganda are taking part in HIV research activities that help strengthen communication about HIV prevention and treatment, and provide important lessons to researchers.

William Kidega, of UVRI-IAVI HIV Vaccine Program, tells the story.
More than one million people live in the fishing communities scattered along the shores and islands of Lake Victoria. Due to their geographic isolation, low literacy levels, high mobility, general attitudes towards risk, and the near absence of a wide range of basic health services, these people are vulnerable to a variety of infectious diseases. As might be expected, they have been hit especially hard by the HIV epidemic. Early data emerging from an ongoing study conducted by the Uganda Virus Research Institute (UVRI) and funded by the European and Developing Countries Clinical Trials Partnership (EDCTP) reveal that 27.5 per cent of the population is living with HIV, compared to a national average of 6.4 per cent. Even more disturbing, incidence data which reflect on whether prevention strategies are successful in reducing the number of new infections, reveal that the fishing communities are becoming infected at a much higher rate than the general population.

UVRI has been actively engaged in research on HIV and HIV prevention for the past two decades. Its experience has underscored the importance of engaging those at highest risk of HIV infection in prevention research and treatment programmes. The people of Uganda’s Great Lakes region certainly fit that bill.

So, with funding from the Wellcome Trust UK, a UVRI team is working with the International AIDS Vaccine Initiative (IAVI), and in conjunction with the EDCTP-funded research, to field test a number of novel community engagement approaches to distribute information on HIV and sustain the interest of Lake Victoria fishing communities in HIV prevention research. This work is of particular importance to long-term HIV prevention research, especially the large scale clinical trials necessary for AIDS vaccine development.

Effective communication is obviously critical to community engagement. To help devise a successful communication strategy, the team first systematically analysed the social and behavioural patterns of the fishing communities and prevailing awareness about HIV. These studies revealed, among other things, that most people in the communities surveyed are unaware of existing HIV prevention options and, in any case, have very limited access to them. The research also suggested a handful of potentially effective communication strategies. In particular, the team concluded that it should harness sporting events (football, pool/billiard games and boat races) and other entertainment—such as music, dance and drama—to communicate HIV information and introduce communities to prevention research. In addition, the team decided to use community dialogues and information seminars to help spread the word about prevention research and ensure the accuracy of the message.

These strategies are all now being used to reach boat builders, fishermen, sex workers, community leaders, beach management units, and restaurant and lodge workers across the area. The turnout at such events has generally been overwhelming, with most people staying from start to finish, providing many opportunities to share information on HIV prevention and related research.

The team has also worked to develop communication processes that are relevant and responsive to community needs, and deployed them to educate people about available methods of HIV prevention: abstinence, effective condom use, monogamy or faithfulness, and medical male circumcision. It has, for instance, conveyed the importance of voluntary HIV counselling and testing as an entry point to prevention through the performance of songs and poems composed by artists within the community. These messages are also integrated into commentaries during sponsored soccer matches and during interludes at other sporting events.

Benefits to researchers

Team members have also learned that the information seminars and community dialogues benefit not just the community, but the researchers as well. These events give researchers a better understanding of the prevailing myths and misconceptions about HIV and HIV research, and a clearer sense of the factors that affect the health of people living in fishing communities. This understanding is critical to their ability to address community expectations and needs in the conduct of their research.

The team has learned, for example, that most fishing communities perceive themselves to be at higher risk of death from accidents such as drowning, than from HIV. This perception contributes directly to high-risk behaviour. Conversely, given the prevalence of HIV infection, some community members simply assume that they are living with HIV —and may dispute the accuracy of test results that turn out HIV negative. For the study team, this enhanced understanding of factors influencing behaviour, attitudes and practices has been critical to the successful conduct of HIV education, the substance of HIV prevention messages and the design of HIV research.

The team has also found that its understanding of the social and behavioural characteristics of fishing communities has played a vital role in developing effective strategies for sustaining public interest in HIV prevention and research activities. It has found, for example, that conventional modes of information delivery—such as posters, brochures or flyers—tend to be ignored. HIV prevention messages, it turns out, are best delivered in relaxed settings and in entertaining ways.

The initiative has also shed light on the expectations and needs that are likely to feed into any HIV research conducted in fishing communities. Such work cannot be efficiently conducted without ensuring access to basic health and HIV services for the community: marginalised communities asked to participate in such research often ask, “What is in it for us?” By establishing strategic partnerships with health care service providers, the team has supported the provision of such basic services and that has widened the reach of HIV prevention messages and the acceptance of HIV prevention research.

Finally, understanding the leadership hierarchy within communities is critical to the success of both public health education and HIV research efforts. Outreach teams working in such communities must recognise the importance of engaging local leaders and resource persons as entry points for outreach activities. They can play a vital role in community mobilisation and do much to ensure sustained community support. We credit the positive outcomes of our initiative in large part to the active support and ready cooperation of such people.

What does it mean to talk about the right to the highest attainable standard of health? How have our perceptions and our actions changed in the past few years?

Paul Hunt, UN Special Rapporteur on the right to the highest attainable standard of health (2002-2008) shares his perspective.

The foundations for the fundamental human right to the highest attainable standard of health (also known as the right to health) are in the Universal Declaration of Human Rights. The right is in major legally binding international human rights treaties that countries have drafted and chosen to sign up to. It is part of what is known as the International Bill of Rights. Until 2000, however, it was not clear what the right to the highest attainable standard of health meant. In that year, a group of international experts agreed a document, called General Comment 14, which sets out in some detail what is understood by this human right. These experts were chosen by governments but, once appointed, were independent. They drew upon international human rights, as well as good health practices. They benefited from the expertise of the World Health Organization (WHO) and civil society organisations. The right to health provisions of most international treaties are only a few sentences, whereas General Comment 14 has 65 paragraphs. It transformed the right to the highest attainable standard of health from a slogan to something that can make a constructive, concise contribution to health-related policies, programmes and practices.

What does this human right consist of? Briefly, it encompasses medical care, as well as access to safe drinking water, adequate sanitation, a safe working environment, access to health-related information and education and other critical pre-conditions of good health. Moreover, it places an obligation on governments to address discrimination and inequality. The right to the highest attainable standard of health requires governments to enhance access for disadvantaged individuals, communities and populations. In other words, it has a social justice component. It also requires that governments put in place arrangements that facilitate the active and informed participation of those affected by health-related policies, programmes and practices.

Crucially, the right to the highest attainable standard of health is subject to progressive realisation, i.e. no government is expected to realise it overnight – or even in 10 years – but to progressively work towards its realisation. This means we need indicators and benchmarks to measure whether or not progress is being made. The right to health is also subject to resource availability. In other words, more is demanded of Canada, than of Chad. Independent monitoring and accountability are crucial elements of the right to the highest attainable standard of health. Too often today, the same body is responsible for delivering and regulating health-related services, as well as holding those responsible to account; from the right to health perspective, this is problematic. At the core of the right to health is an equitable, integrated, responsive, effective health system that is accessible to all and of good quality.

This human right is not just the preserve of international human rights systems. It is enshrined in the WHO constitution, Declaration of Alma-Ata, Ottawa Charter for Health Promotion and other important documents agreed by the health community. Over the last six years, the UN General Assembly and the UN Commission (now Council) of
Human Rights has routinely received reports on numerous aspects of the right to health, including water and sanitation, the Millennium Development Goals, maternal mortality, the skills drain, access to medicines, the right to health responsibilities of pharmaceutical companies and so on.

Numerous constitutions and other national laws include the right to the highest attainable standard of health. Of course, some of these provisions are little more than adornments. But some are not. Some are giving rise to important cases that are leading to improvements in health-related services. For example, the Colombian Constitutional Court recently ordered a phased re-structuring of the country’s health system by way of a participatory and transparent process based on current epidemiological information. The Court’s decision relies upon the right to health.

The right to the highest attainable standard of health, as well as other health related rights are now being taken seriously at the international, national and local levels. There can be no doubt that the right to the highest attainable standard of health encompasses social determinants, particularly poverty and discrimination. This fundamental human right places legal obligation on governments to tackle social determinants where they harm health.
As the UN and many others have devoted more attention to the right to health over the last ten years, new human rights tools and techniques have been developed, as articles in this issue of Health Exchange show. We no longer only think in terms of taking test cases in the courts, letter-writing campaigns and ‘naming and shaming’ – although these continue to have an important role to play. Additionally, we use indicators, benchmarks, impact assessments, budgetary analysis and so on. Accountability is now understood to be so much broader, and more subtle, than judicial accountability, which is accountability of the last resort. There are other forms of accountability such as national human rights institutions, public inquiries, local health councils, regional health conferences with grassroots participation, maternal health audits or reviews and so on. Human rights accountability is not just about blame, sanction and punishment. It is about finding out what works, so it can be repeated, and what does not, so it can be revised

Paul Hunt UN Special Rapporteur on the right to the highest attainable standard of health (2002-2008)
Professor of Law, Human Rights Centre, University of Essex

Drug users in Phnom Penh were once without self esteem, felt ashamed and worthless and had no concept that they were entitled to, and deserve, the same quality of life and health care as other Khmer citizens. Previously, no services existed for the adult drug using community and until Korsang was founded in 2004, there was no needle exchange programme serving adult intravenous drug users (IDUs).

Many hospitals and clinics in Phnom Penh discriminate harshly against intravenous drug users (IDUs), including IDUs living with HIV. Commonly, doctors refuse to admit or treat them, regardless of how critical their health situation is. Patients who are admitted are frequently ignored and go untreated for days. In hospital, neglect and withdrawal without medical assistance, means nearly 100 per cent of IDUs living with HIV leave before finishing treatment. Those unfortunate enough to become involved in the Cambodian drug user detention system befall the same fate.

Korsang is a grassroots harm reduction programme in Phnom Penh working with the Khmer population to prevent HIV and other drug related harm. HIV transmission among IDUs in Phnom Penh is a growing problem, with an estimated infection rate of 34 per cent. The two main reasons are lack of proper education about the risks of drug use and poor access to good health care services.

For IDUs living with HIV, there is a serious lack of public services. Unsanitary living conditions and lack of access to antiretrovirals (ARVs) and other HIV medicines, means many people are prematurely and unnecessarily overcome by opportunistic infections. Many infections develop as a result of abscessed injection sites and in some cases are fatal.

The focus of the Korsang team is to engage in intensive, harm reduction street-based services. We do not discriminate against clientele based on age, and serve a population of over 3,300 users between 12 and 55 years of age. Korsang targets Cambodians who are engaged in injection drug use and yama use, who are at serious risk of HIV and other health-related hazards that accompany drug use and high-risk sexual behaviour. Korsang staff visit 20 areas where street-based injection drug use is a serious issue and sex worker areas where yama and unprotected sex go hand in hand. We have created multiple educational programmes to reduce the risk of HIV infection among IDUs and offers a menu of services and options for the drug users of Phnom Penh including a drop-in centre, citywide street-based outreach, needle and syringe distribution, peer education, methadone transportation, methadone case management, referral and advocacy, a transitional living programme and HIV testing.

Since Korsang began serving drug users, many opportunities to reduce the risk of drug-related HIV transmission and other drug related harm have increased. Our on-site medical services have been invaluable in this sense. Since drug users in Cambodia have no immediate access to medical care, Korsang has an on-site medical infirmary with a full time doctor and a medical crisis team of three full time staff and three part time staff. The medical team treats an average of 1,000 drug users each year, and case manages and advocates for another 250 drug users who require in-patient care at a local hospital. The majority of our participants have never been to see a doctor and are therefore unvaccinated, undiagnosed and untreated for other chronic illness such as diabetes, thyroid dysfunction and asthma.

The Korsang medical team is not only responsible for administering basic first aid in the field, but also for the transportation of sick and injured participants to our infirmary and the hospital. If a participant is hospitalised, the team is responsible for making sure food is provided, along with a mat, mosquito net and water. Hospitals in Cambodia provide no personal provisions, so the medical team provides 24-hour supervision and advocacy to inpatient participants. The team also provides Direct Observation Treatment (DOT) for participants on ARVs and tuberculosis medication throughout Phnom Penh. Outsourced services to local hospitals are paid for by Korsang and include pre- and post-natal care, midwife consultations, deliveries, minor and major surgery, X-ray and electrocardiography, severe emergency trauma services and all in-patient care. Finally, the medical team also tends to participants who die, ensuring each has a proper cremation and burial.

Some of the medical issues that participants are treated for include: HIV and AIDS and related opportunistic infections, injection-related infections, for example: cellulites, abscesses, endo-cardnitis, skin ulcers, septicemia, gangrene, hepatitis B and C, as well as acute tetanus. We see a fair amount of needles that have broken off and are lodged under the skin. This situation requires minor out-patient surgery, which our clinic provides. Other medical conditions are less associated directly to injection related behaviour, but are linked with the harsh and chaotic lifestyle drug users who live in Cambodia endure. These conditions include, but are not limited to: gun shots, stabbings, machete wounds, stoning contusions, broken bones, amputations, tuberculosis, eye infections, pregnancies and subsequent births, sexually transmitted diseases, chest infections, parasites and food- and waterborne disease, malnourishment and vitamin deficiency, as well as an array of other medical problems.

The medical clinic is dedicated to providing the best possible health and medical care for all IDUs, providing care which is focused on the patient, their needs and desires. The staff focus is on the whole patient, not just the illness or condition, and every patient is treated with dignity, compassion, confidentiality, respect, and as a person who is involved in decisions regarding their own treatment and care.

It is clear to Korsang that drug users need, and are entitled to, medical facilities that are 100 per cent dedicated to their special needs, services that do not discriminate, stigmatise or criminalise them. We hope our model will spread to other locations, both regionally as well as globally.

In 2007, the People’s Health Movement in Uruguay took a critical stance on the right to health and has been campaigning vigorously as part of the Global Campaign for the Right to Health.

Fernando Borgia shares the experience.

Uruguay is a small country, both geographically and in terms of population. Ninety per cent of people live in the capital and in the departmental capitals. There are however, small numbers in the countryside and people crowd around the horse changing posts and railroad stops. These populations, and also those that live on farms, comprise what we call “the deep inside” or “the real country”. There are few opportunities to receive information, exchange and discuss views on human rights topics, and to be heard. We decided to prioritise these populations in the ‘Right to Health Campaign’ in 2007 and linked up with the People’s Health Movement (PHM) globally.

A handful of volunteers from Montevideo held more than 80 briefings in over 60 locations in 19 departments to promote active participation in regional and national social health forums. We held preparatory meetings and regional forums, and shared these discussions at the 3rd Uruguayan Social Health Forum in 2007.

In Uruguay, we can say that we had a genuine dialogue about the right to health with more than 2,500 people. Lessons from Uruguay, from its people, and the problems and challenges they face, became a huge experience for us.

How useful was this mobilisation? Did it help us get closer to achieving the right to health? To answer these questions I should point out the context. Since March 2005, Uruguay has had a progressive government which recognizes health as a human right, and as a responsibility to be ensured by the State. This was a significant change from the previous government. When we held the forum in 2007, the law creating the National Integrated Health System (Sistema Nacional Integrado de Salud – SNIS) was still in debate; it was approved in December 2007. So, the forum was an area of discussion focusing on the health needs of people and their relationship with the health system. It showed the importance of social organisation in demanding rights, and the inter-relatedness of citizens and the health system.

Since the establishment of the SNIS we have continued to advocate for the right to health through our research project “The role of primary health care, community and rural clinics in the new SNIS”. The SNIS places special emphasis on primary health care, but as in many countries, the term “primary health care” has been used to describe multiple ways of operating the primary care level without a real development of primary health care in the original sense of the Alma Ata Declaration.

The creation of the ‘Movement of Users of Private and Public Health’ as a formal organisation in November 2007 was an important step. There are some particularly remarkable facts about this movement. It has members in all 19 departments of Uruguay. It has been recognised as an official task force by the national health authority. It has appointed one of its leaders to the National Board of Health, which is the highest health policy authority with citizen participation such as workers.

At the 4th Uruguayan Social Health Forum in Rio Negro (November-December 2008), we emphasised the importance and validity of the collaboration between different movements. Colleagues from the PHM in other parts of Latin America, such as Brazil also participated. PHM can be thought of as a common platform that unites various groups that make up the forum. In most of the groups, many people have endorsed on-line the People’s Charter for Health, the founding document of PHM.

The Social Health Forum is a space to connect national problems and experiences with the Latin American and global agenda for people’s health. It also acts as a chapter of the People’s Health Movement in Uruguay, and serves as a joint space of the Movement of Users of the Private and Public Health, ALAMES (the Latin American Association of Social Medicine), and the Uruguay Medical Union and, to a lesser extent, the Uruguayan Federation of Health (non-medical workers).

We have developed a training agenda for health activism. The most relevant result of the training activities has been to promote an alternative way of thinking in health. The representatives of the movement have modified their discourse, from demanding better health care services to demanding the right to health as a comprehensive vision including the social determinants of health. It is also important to note the growing relationship with trade unions, beyond the health sector, and various community organisations and NGOs interested in the right to health. Building a relationship with provincial governments has also been useful to ask for and to create opportunities for interaction with the Ministries of Health, Labor and Social Security, and Social Development.

Since 2004, we have been collaborating with other organisations in the preparation and presentation of the Annual Reports on Human Rights in Uruguay, especially in chapters concerning right to health, advances and setbacks in the country. This is the only independent systematic and collaborative report we have. In 2008 we edited jointly with Ideas-Action and Change (Ideas Acción y Cambio – IDAC, a social group from small town) a newspaper called ’People’s Graffiti’. We also have a blog, although it is not updated systematically.

When we linked up our national campaign with the People’s Health Movement, we found that many groups around the world are taking up the concept of the right to health, and using it as the standard for health systems and as a framework for making demands on their government and other duty bearers. We hope that by linking these local and national level groups together, we can help support them and build global awareness of the Right to Health.
Fernando Borgia

Nowhere is the global health worker crisis more acute than in fragile states – those countries where the government cannot or will not deliver core functions to the majority of its people. Since the civil war, Liberia has an absolute shortage of health workers. Merlin is working with the government to help train health workers and rebuild the shattered health system.

Midwife Sarah Shaffa teaches at the Merlin/Ministry of Health Midwifery School in Liberia, remote south eastern region

Amy Waddell tells the story.

In 2007, fragile states received only 38.4 per cent of Overseas Development Aid. Fifty per cent of that benefited just five countries, with the rest divided up among the remaining 41 states. Yet fragile states carry a disproportionate level of the global health burden: one third of women who die in childbirth and half of all children who die before their fifth birthday live in fragile states.

Sustained investment in health, especially health workers, in fragile states is vital to save lives and to meet the Millennium Development Goals.

Liberia

Before the civil war, Liberia boasted 237 doctors providing health care for a population of two million people. By 2005, an evaluation estimated there were less than 20 doctors left in the country. Fourteen years of government coups and rebel clashes had shattered the health system and caused the death or emigration of many qualified health workers.

With the commitment of President Ellen Johnson Sirleaf, the Ministry of Health and Social Welfare (MoH&SW) is tackling the huge challenge of rebuilding Liberia’s health infrastructure including the health workforce – yet with minimal resources.

Since 1997, Merlin has been supporting the MoH&SW. Initially running mobile clinics for people displaced by fighting, the organisation has expanded its role to support the delivery of a third of the country’s health care. Merlin’s key focus is the training and supervision of health workers; helping to implement Liberia’s ambitious National Health Plan, which highlights the need to strengthen human resources.
In Liberia the shortage of health workers is most acute in rural areas, such as the isolated south eastern region. Until June 2009, there had not been a permanent doctor in a county of 185,000 people for almost six months.

Reaching the south east can take a 20 hour drive on dirt roads that are barely passable during the rainy season, from March to October. Health workers sent by the MoH&SW make their own way to take up their remote roles, often only to resign and return to the capital, Monrovia, months later.

With inadequate housing and few schools, there is little to encourage health workers to stay. Leaving their families in Monrovia, Liberia’s health workers struggle both to support their main family home and feed themselves; a bag of rice in the south east costs $45 instead of the usual $30, because of transport costs. Health workers receive no added incentives to live and work in this remote region.

Investing in Health Workers

An example of one project addressing just such issues is the Midwifery Training School, based in Grand Gedeh.

Supported by Merlin, this MoH&SW school re-opened in December 2008 after a forced closure of almost 20 years. Returning to pre-war ideals, a two year full-time course, accommodation, uniforms and materials are provided free of charge to all students.

In a bid to retain health workers in the south east, the school only advertises across the region’s six counties – encouraging men and women, aged 18 to 45, to apply for the 40 places that are offered, on average, each year. The sole condition for the Midwifery School’s free training: that students sign a bond to work in their communities for at least three years after graduation.

By recruiting future health workers from their home counties, areas where health workers are most sparse, the Merlin-supported MoH&SW school offers a sustainable solution to Liberia’s health worker crisis.

For now, it is a small step towards equipping Liberia with the estimated 1000 midwives it needs; by 2010, over forty students will be providing pregnant women in isolated communities with rare access to a trained health worker.

Merlin believes investing in health systems and health workers is the most effective use of funding to the sector. Investment, especially in fragile states, is vital – without it, the world has little chance of reaching the Millennium Development Goals for health by 2015.
With this in mind, Merlin’s international campaign, Hands Up For Health Workers, is calling for urgent and sustained investment in health workers in fragile states. Central to this are health workforce plans which cover the equitable distribution of health workers and the incentives required to keep them where theyare most needed.

Campaign for change now at www.handsupforhealthworkers.org
Amy Waddell, Merlin

Lack of appropriate health workers is a major reason why health services are not reaching poor people in low income countries. Fifty seven countries – mostly in sub-Saharan Africa – do not have the minimum health workforce numbers proposed by the World Health Organization (WHO). In the least developed countries only 35 per cent of pregnant women have access to skilled birth attendance.

How did things get so bad?

Reasons include expanding demand for health services, failing economics leading to reduced public services, piecemeal approaches to addressing health workforce problems and, in general, a lack of appreciation of the changing and globalising labour market in health.

The health workforce was low on the agenda for ministries of health and donors alike, partly because the problems seemed unsolvable. The good news is this is changing. The recognition of the impact of migration and the massive funding increases for HIV and AIDS, tuberculosis and malaria programmes highlights the imperative to address health workforce problems.

Advocacy through the Joint Learning Initiative, the World Health Report 2006 and, as featured in an article here, the Global Health Workforce Alliance, has finally given the health workforce its rightful place on the wider health agenda. Donors are now much more open to funding workforce-strengthening initiatives and even topping up salaries. This issue of Health Exchange provides an excellent range of examples of what can be done when there is a will to address health workforce challenges.

The shortage of health workers – particularly in remote rural areas – is a high profile problem. In some countries, like Malawi, the problem starts with lack of suitably qualified (particularly in science subjects) school leavers to train to be health professionals. Even if there are enough applicants, the lack of training facilities may cause a bottleneck. The buildings may be there, but as the article on pharmacy schools in Africa shows, the teachers may not.
Low training output of new health professionals is supplemented by many countries – not just in the North – by international recruitment – often of volunteers. The Director of the Royal College of Nursing in the UK explains how nurses from the North are working in low income countries with health workforce shortages.

In a rapidly changing labour market, health workers now make choices about what work they want to do, for whom and where. This is why it is so important to understand the job preferences of young graduates, as described in the article on research being carried out in Thailand, Kenya and South Africa. The report from Liberia highlights the challenge of attracting health workers to rural areas.

Faith-based organisations make a major contribution to health service provision – particularly in Africa. The article from the National Catholic Health Service in Ghana explains how they commissioned a study and have developed their retention strategies, which include bonding for training, improving job security and financial allowances, to address the findings. The article from Lesotho’s Christian Health Association (online only) reports on similar experience.

Increased workload, related to both staff shortages and treatment of highly infectious diseases, is having a serious impact on the health of remaining staff, leading to sickness and often to resignation. The International Council of Nurses explains why carers need to be cared for and the dramatic impact this can have on staff retention.

Many health workers decide to take their skills to another country where working conditions and pay are better. Such losses to the country of origin have a serious impact on health services and a raft of strategies to manage migration has been introduced. The most notable is the WHO Code of Practice on the International Recruitment of Health Personnel, still in draft. Earlier drafts and similar codes have stressed that in addition to curbing indiscriminate international recruitment, countries should do more to retain their health workers. The article about managing migration of pharmacists (an interesting group, as we usually only hear about doctors and nurses and often assume the private sector is covering the issue) describes the need for a comprehensive package of retention strategies.

Developing strategies to retain health workers or plan for appropriate numbers requires both human resource planning and management expertise, and appropriate tools. A number of workforce planning tools have been developed, but the Workforce Indicators of Staffing Need (WISN) –developed over a decade ago is a tool that promotes a bottom-up planning process.

Re-thinking who does what is an important part of workforce planning. Recently there has been much emphasis on task-shifting and using non-formal health workers to improve access to health care, as explained in the paper on the role of lay health workers.
Information about what works or does not work, need to be communicated. The PAHO observatory is an excellent example of a process to monitor and share knowledge, to help managers develop more appropriate strategies to meet the workforce challenges.

Shortages of health workers are indeed a problem, but the importance of helping health workers to provide quality services efficiently cannot be over-emphasised. It is notable that the first decade of the 21st century has seen recognition of the need to address health workforce problems seriously. The following pages will provide the reader with some examples of what is actually being done.

Access to essential medicines and medicines expertise is a basic health service requirement. The way that medicines are selected, procured, delivered, prescribed, administered and reviewed is the key to optimising medicines therapy for patient care. To ensure adequate medicines management there is a need for high quality education to prepare an appropriately-trained pharmaceutical workforce for all countries.

Heads of pharmacy schools in Africa, as with all global regions, are facing educational challenges to meet local medicines needs. These challenges are many, ranging from the physical infrastructure and laboratory teaching equipment to the world-wide shortage in academic capacity to fill teaching positions. Seven Heads of pharmacy schools in Africa met recently to discuss how to tackle this situation in order to provide solutions from which the global educational infrastructure can learn.

Sarah Whitmarsh of the Pharmacy Education Taskforce tells the story.

In August 2009, Deans or Heads of schools of pharmacy from Ethiopia, Ghana, Kenya, Malawi, Tanzania, Uganda, and Zambia, held a three-day workshop in Nairobi with the World Health Organization (WHO), United Nations Educational, Scientific and Cultural Organisation (UNESCO), and the International Pharmaceutical Federation (FIP) Pharmacy Education Taskforce. They discussed the challenges of educating pharmacists in resource-limited settings in sub-Saharan Africa and developed an action plan to address those challenges.

There are global issues in operation, which the seven leaders identified as being most pertinent in facing the local challenges. Getting qualified and experienced academics to fill teaching positions is a key issue, as is setting up independent quality assurance procedures within institutions. However, the leaders identified ways to tackle this; a recent pilot project conducted in Zambia and Ghana illustrated that cross-border cooperation (in quality assurance processes) can contribute significantly to educational quality and can be cost effective.

Professor Mahama Duwiejua said the FIP Global Framework for Quality Assurance of Pharmacy Education, a document which can be used by governments or institutions to establish or further develop quality assurance systems, was a useful tool to aid the assessment of quality at the Kwame Nkrumah University of Science and Technology in Ghana. Prof. Duwiejua said, in Ghana, quality assurance systems exist at three levels: the National Accreditation Board, a Quality Assurance (QA) Unit in the university, and the Pharmacy Council. Prof. Duwiejua said the use of the QA tool revealed weaknesses among the institutions, such as lack of transparency and accreditation criteria.

The African leaders also shared strategies they used to address problems at their institutions. For example, Dr Lungwani Muungo, Head of the Pharmacy Department at the University of Zambia has implemented a new staff development tutor programme. The tutor programme addresses academic capacity on two fronts: it offers teaching experience for young academics and also helps better manage available resources in the department’s faculty.

Although the needs within their countries are still significant, the African leaders said they were seeing improvement. For example, they reported an expanded intake of students at their institutions and an increase in employment of pharmacists in the clinical field, especially in private hospitals. Within the last several years, for example, Kenya has focused on increasing the number of well-trained technicians to augment the workforce, and optimising the current skill-mix. Zambian pharmacy schools have placed a stronger emphasis on clinical training and medicines-related public health issues, strategies which are increasingly being adopted by university curricula across the globe.

Encompassing the various strategies shared by the leaders, in addition to evidence-based literature gathered by the Taskforce, small group discussions and roundtable consensus consultations led to a work plan to address these challenges.

The leaders saw potential for further development and collaboration with partner organisations like the Taskforce in four key areas: academic capacity, quality assurance, strategic partnerships, and advocacy and communication. They especially focused on partnerships as the way forward in overcoming challenges due to limited resources. One prominent idea was to reach out to the diaspora and alumni and engaging stakeholders within the community and industry. Forming a regional network of pharmacy educators in Africa was seen as a key activity for the action plan. The leaders said that educating the community and government about the role of pharmacists would help empower pharmacists at all levels. All the leaders agreed that advocacy and better communication were key mechanisms to mobilising workforce and resources.

The proposed three-year work plan will include activities such as establishing an African regional database of pharmacy courses and setting up a team of African quality assurance experts.

Pharmacy education development is a key strategy for the Taskforce in the effort to redress critical shortages of pharmacists and pharmacy technicians, particularly in sub-Saharan Africa where some of these needs are most acute. Scaling up of the pharmacy workforce is necessary to ensure improved access to and rational use of medicines. The Taskforce, and the African leaders’ forum, advocate for needs-based pharmacy education development, meaning education that is determined by evaluating the services required nationally and the competencies needed to provide such services.